Tuesday, July 22, 2014

Guns and Dementia

A new survey looks at access to guns by people with dementia. It finds that caregivers and family members of people being checked for problems with thinking didn't consistently remove guns from their homes or keep them locked up.

The study underlines the need for doctors to ask caregivers if they have guns in the home and, if so, advise them on safety measures to take, the researchers say.

In the United States, there is "a significant presence of firearms in the homes of patients with dementia, and many of these patients suffer from delusions and hallucinations, some of which can be paranoid, persecutory, or hostile," says Jason Hsieh, a medical student at Cleveland Clinic Lerner School of Medicine.

The results were presented at the Alzheimer's Association International Conference (AAIC) 2014.

Suicide, Homicide
In the U.S., 27% percent of people over the age of 65 own a firearm, Hsieh says. "In general, almost 40% of households in the U.S. contain a firearm, and surprisingly, in households with a firearm, the average number of firearms is 6.6," he says.

The elderly have the highest suicide rate of any part of the population, and firearms are the most common, as well as the most fatal, method of suicide. Data from the National Trauma Databank show that as people get older, the proportion of gun injuries that are self-inflicted rises. Other data show that as they age, people are less likely to survive a gunshot and less likely to return home after recovery."In addition to suicide, elderly individuals can be the victim of homicide, and this often happens from their caregiver," Hsieh says. "Most of these events happen at home, and again, just like suicide, using a firearm is the most common method."

Also, it's been shown that caregivers, families, and loved ones with dementia often don't remove guns from the home as the dementia gets worse, he says.

The concern comes from the fact that people with dementia more frequently behave aggressively than those without it. Increasing dementia is linked with worsening agitation and aggression, along with delusions – particularly, mistaking a person for someone else, he says.

Study Details

Included in this analysis were 495 people, with an average age of nearly 80. Most of the patients were women (63%).

Of the group, 378 (77%) qualified for a diagnosis of dementia, and 64% were already diagnosed with depression or qualified as depressed, the researchers say.

Of the 378 people with dementia, 178 had delusions. Among them, 114 of the delusions were described as paranoid or persecutory (i.e. delusions that someone was stealing from them or other abuses).

Ninety-two of the people with dementia had hallucinations. Of those, 21 were described as hostile, Hsieh says. "In other words, they see someone attacking them, they see an imposter in the room.”

Of the overall group, 89 of the people had a gun in the home. Of those with a gun in the home, 62 (71%) had dementia, 33 (37%) had delusions -- of which the majority (73%) were persecutory or paranoid delusions -- and 15 (17%) had hallucinations, roughly half of which (47%) were hostile hallucinations.

The researchers then compared the people with and without access to guns. They found that in general, patients living in homes with guns tended to be younger, to live in their own home rather than a supervised setting, and to be male.

'An Important First Step'
"Even though there's still a lot to study, this is an important first step towards understanding the public health concerns about this issue," Hsieh says. "It's important for physicians to assess for the presence of firearms and recommend to the family that they take appropriate steps."

The study was large, but it used data from a single memory clinic, and patients were self-selected, since they were checked for problems with thinking. It's also possible that gun ownership may be under-reported.

Other U.S. studies have found that as few as 4% and up to 60% of doctors dealing with similar patients and their caregivers or families say they ask about firearms in the home at the initial visit, Hsieh says.

"I think the most important thing we try to focus on is, first, ask about this," agreed Babak Tousi, MD, of the Lou Ruvo Center for Brain Health and senior author on the paper. "Doctors need to ask and assess when there's a concern."

A Safety Issue Like Any Other

Beth Kallmyer, vice-president of Constituent Services for the Alzheimer's Association in Chicago, says her organization works on a daily basis with families about many safety issues.

"With an illness that's progressive and impacts your [mind], there are all kinds of safety issues that actually come up, and the use of guns is a safety issue, not unlike driving, using power tools, and cooking. I think one of the biggest challenges for families is to sort out when that safety becomes a problem that could be dangerous to the person with the disease, whatever the issue is, whether it's driving or guns," Kallmyer says.

"So it's important that we educate people around that as the person’s disease progresses. We have to continually reassess safety issues depending on who the person is, and what's going on."

Just because a person with dementia may have past experience with guns doesn't mean they'll still be able to handle them safely once they have the disease. And given the worsening nature of the disease, it's not clear at what point they may become confused, she says. "They might not recognize a family member or a caregiver, they might think they're an intruder, and when guns are present, really bad things can happen."

Some families opt to simply remove the ammunition, Kallmyer says, but patients may still be able to get other ammo. Also, "if there's a situation where someone has a gun in their hand, and emergency responders come to the house, they're not asking if it's loaded. So if you play it out, there are issues around people who don't have the [thinking] ability to understand the situation. Safety with a gun requires [thinking] skills, and once you don't have that, it could lead to a dangerous situation.

"So when we talk to families, we recommend that they remove guns and ammunition from the home when somebody has dementia," she says.

The Alzheimer's Association has a toll-free line for families, staffed by counselors and social workers who can help with questions about these kinds of safety issues. They can also help come up with solutions that fit your family, free of charge (1-800-272-3900).

These findings were presented at a medical conference. They should be considered preliminary as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.